Coan’s interest in spouses and self-regulation dates to when he was the lab coordinator for John Gottman, possibly the most famous researcher on healthy and damaged marriages. There Coan saw how couples in strong marriages would support one another even in the middle of a conflict, often through an affectionate touch or a message that diffused growing tension.
Those observations came back to him while he was earning a PhD in clinical psychology at the University of Arizona and treating World War II–era veterans suffering from post-traumatic stress disorder (PTSD). One patient refused even to begin trying preliminary treatment, such as talking about his wartime experiences.
“I couldn’t get him to do simple relaxation techniques. Anything we worked on made him too afraid,” Coan said.
On the third visit, the man mentioned that he wanted his wife to attend future sessions. Coan readily agreed. At the next appointment, he guided the man through progressive muscle relaxation, which involved tightening and flexing each set of muscles and then relaxing them. The man’s wife offered to do the exercises with him.
As soon as she clasped his hand, the man’s demeanor changed completely. Suddenly, he was mentally present and ready to work with Coan. The power of holding hands extended throughout the process. Whenever the man ran into a stumbling block, his wife would take him by the hand and he would relax.
“I couldn’t get him to talk at all unless he was holding his wife’s hand. It was like a magic switch,” Coan said. “He would be nervous, fidgeting, wouldn’t make eye contact, and she would reach over and grab his hand and I had him. He wasn’t off in some other space managing some thoughts and feelings that I didn’t have access to. That really left an impression.”
TO TRULY UNDERSTAND THE RESEARCH on the impact of our close relationships on our mental health and self-regulation, let’s go back to the late 1950s in England. Specifically, Camberwell, a district in southeast London, where a British sociologist named George Brown led a team that followed male patients who had been in a mental hospital for more than two years. They wanted to better understand why long-term psychiatric patients in hospitals rarely successfully reentered society. Some of the patients in their sample had returned home to a spouse or parent, while others had had to find paid lodging in boardinghouses.
To Brown’s surprise, patients with schizophrenia who were discharged to the care of loved ones actually fared worse than those living with strangers. They were more likely to relapse in the environment that we might assume would have been more socially supportive.
How could that be? Brown lacked any body of research to help him understand this finding. No British scientists had investigated the environment in which schizophrenia patients were living as a potential factor in their mental health.
Intrigued, the team created a research study to explore the role of family relationships in recovery from schizophrenia. As they interviewed patients and their families, they began to see patterns in the emotional climate of their lives. When patients lived with critical, hostile, and overly involved family members—typically a parent or spouse—they fared worse at follow-up. Those who lived in boardinghouses experienced no such stressors.
Through this research, Brown and his colleagues developed a concept called “expressed emotion,” which has proven over the past six decades to be a significant factor in mental health. Expressed emotion (EE) refers specifically to when a key relative of the psychiatric patient speaks about that person in critical, hostile, or emotionally overinvolved ways. The team worked up a set of questions called the Camberwell Family Interview, which took one to two hours to complete. The conversation was recorded, and a trained coder counted up comments made by the family member in order to gauge the level of EE.
Comments deemed critical could be something negative about the family member or they could simply be comments delivered in a critical tone of voice. Hostile remarks could be aspersions on the patient (“She’s very selfish and self-involved”) or rejection and expression of dislike (“I can’t stand to be around him anymore”). Emotional overinvolvement included dramatic or overprotective attitudes about the patient (“We can’t be apart—it would kill me”).
In a series of papers, Brown’s team demonstrated that schizophrenia patients with family members high in expressed emotion were more likely to relapse. The scientific community followed up on this research. One discovery was that when a family member with high EE entered the room, a patient’s blood pressure spiked. By contrast, if a low-EE relative came in, their presence helped the patient self-regulate.
Over the decades that followed, study after study connected high EE with worse outcomes among patients with depression, bipolar disorder, anxiety, post-traumatic stress disorder, eating disorders, and substance abuse. Indeed, the connection in depression appears to be stronger than in schizophrenia—at even lower levels of family members’ expressed emotion, there’s a higher likelihood of relapse.
This breakthrough helped doctors predict which patients might need more support during their recovery, because of high-EE relatives. They could offer these families additional counseling, treatment, and help in building communication skills. But the process of assessing EE took hours: first the one- to two-hour family interview, then two to four hours of coding by an individual trained to detect the voice changes that indicated criticism. The training itself took two weeks or more and could be hard to obtain. It was simply impractical for most busy doctors’ offices.
So researchers started looking for a shortcut.
Enter Jill Hooley, a psychology professor at Harvard University, and her colleague John Teasdale of the Medical Research Council in Cambridge, England. The pair tried simply asking psychiatric patients about their most important relationship, how critical that person was on a scale of 1 to 10, how critical the patient was of that person, how upset the patient felt when criticized, and how upset the other person felt when criticized.
This measure—“perceived criticism”—turned out to predict relapse in depression just as well as EE. Hooley and Teasdale found that every single patient in the hospital for depression who rated their spouse at 6 or higher relapsed within nine months of discharge. No patient who rated their spouse at 2 or lower relapsed during that period.
The simplicity of this measure, which could be assessed in less than a minute with the patient, led to a slew of studies connecting high perceived criticism with relapse in substance abuse, obsessive compulsive disorder, agoraphobia, and psychosis. Perceived criticism also predicted future hospitalizations for patients with bipolar disorder.
We would expect patients with verbally abusive family members to fare poorly. By comparison, the kind of criticism involved in these studies seems mild.
“Most people wouldn’t see it as problematic. It’s an expression of dislike: ‘It really bothers me when he walks into the house and tracks mud on the carpet,’” Hooley told me. “This is highly predictive of bad outcomes. We were really curious about why that could be.”
After all, criticism is an inevitable part of human life. It’s how we learn. Our brains are inextricably linked to our social context. Certainly, you can’t parent a child without some kind of critical feedback.
Something had to be going on at a deeper level for those individuals who were vulnerable to depression, anxiety, or another psychiatric condition.
Hooley started to investigate. Her lab recruited college students with a depression history. All had to have been stable for at least six months leading up to the study, with no current mood problems. They also recruited students with no depression history to serve as the control group.
Then Hooley did something that most people dread. With their permission, she recorded their mothers over the phone making critical remarks about them.
“The mother would begin by saying something like, ‘Katherine, one thing that really bothers me is your tendency to speed. The way you drive. It worries me to think that you’re in the car. I really wish you would slow down
,’” she said.
Next, each participant went for an fMRI scan. The team played a recording of their mother’s critical comments and analyzed the response in their brain.
“Their dorsolateral prefrontal cortex went offline,” Hooley said. “The brain is taking a hit from criticism.”
Only participants with a history of depression showed this response, according to the 2005 paper Hooley’s team published. By contrast, the control participants showed no such decrease in activity for that part of the brain.
All this happened without participants being aware of it. Both the previously depressed participants and the control participants reported being mildly annoyed, despite the extreme differences in how their brains reacted.
“It’s as if this is happening below the radar. They don’t feel that was terrible. They were like, ‘Yeah, yeah, that’s my mother,’” Hooley said. “It’s not too difficult to see how these soft punches could start to provoke a brain that is liable to depression to begin with. It creates these micro-stresses.”
Hooley and her colleagues continued to investigate this phenomenon. In a 2009 paper, they reported that people who recover from depression may face higher risk for relapse if their relatives are critical, because such criticism helps to train brain pathways that are typical of depressive information processing. Basically, when people vulnerable to depression hear this type of criticism from their closest family member, their brain seems to snap back into a depressive mode of operating.
The test for perceived criticism captures both the actual criticism someone hears as well as their interpretation of the words used. People more vulnerable to mental illness often have trouble letting go of negative comments or managing their emotional response. It’s as if negative comments are stickier for them.
Therapists can already harness the power of these findings. By measuring a patient’s level of perceived criticism, they can gauge how vulnerable that person may be. They can adjust treatment in anticipation of these challenges.
The implications for parents are potentially profound. You may not yet know whether your young child or adolescent is vulnerable to mental illness, substance abuse, or an eating disorder. From Chapter 2, we know that at least half of children could develop one of these conditions. To be safe, consider limiting your critical comments to those that are absolutely necessary for redirection. Try to restrain your casual nagging and annoyed tone of voice.
When I first learned about this research, my chest tightened up in panic. I’ve been critical of my children and emotionally invested in their choices since birth! But I forced myself to relax. Tomorrow is a new day. I can always start fresh with a more tolerant outlook. Rather than regretting the past, I try to feel grateful for the chance to try reshaping the present and the future.
FROM THIS RESEARCH, WE KNOW that criticism hurts. But what helps?
Research scientists try to limit any variation in experiment conditions from one person to another so that the results will not be skewed by a factor that nobody thought was important. In a recent study of children with an anxiety diagnosis, one of the graduate students in a neuroscience lab directed by Greg Siegle at the University of Pittsburgh noticed that some of the kids asked for their mom to stand near them while they were being scanned. This is common practice in MRI scans of children, and the scientists allowed it. But they wondered: could that difference sway the results?
The researchers pulled the data for those children. Remarkably, the children with a diagnosed anxiety disorder had brain scans similar to those of typical children—but only when their mother was in the room with them. The anxious kids who were in the scanner alone had more activity around their hypothalamus, in the orbital frontal cortex and ventrolateral prefrontal cortex, all areas of the brain that integrate emotional and physiological reactions to fear and stress. When an anxious child’s mother was physically nearby, these regions of their brain looked just as they did in kids with no anxiety.
“It was absolutely an accidental finding,” Siegle recalled. “When we have another person with us, especially touching us, it seems to do a lot to regulate our emotional reactivity. It’s returning us to a regulated state.”
So does this mean Mom’s presence can cure an anxiety disorder?
Not so fast. First of all, the treatment for anxiety involves small exposure to scary things, so that children’s brains will experience that arousal-relief cycle that creates the ability to self-regulate. If the parent is always there, these kids miss the chance to begin that treatment.
Second, Siegle cautioned against taking a neuroscientific finding and immediately turning it into broad parenting advice before scientists have had a chance to study the impact of that parenting strategy. “Translating an association that we observe in neuroscience into a prescription is really hard,” he said. “Just because something reacts does not mean that the causal chain went the way you thought it did.”
However, it’s a very promising area for research. And parents can do their own experiment with one subject—seeing how hand-holding or empathy may help their own child cope with distressing situations. If you can see a strategy helping your child, do you care if it’s been proven to work for a representative sample of youngsters in a randomized controlled trial? As Siegle put it: “The neuroscience can tell us what rocks to look under for our kids.”
This research is part of a growing body of scientific findings that when people experience empathy or social connection—or even the physical proximity of a supportive close relative—neurons fire in the areas of the brain that govern self-regulation. It builds on experiments showing the power of touch dating back to psychologist Harry Harlow’s monkey studies in the 1960s. Many of the researchers I met while reporting this book have collaborated on the studies: Siegle and Hooley wrote the 2012 paper on perceived criticism together, and Nieves’s boss, Wendy D’Andrea, and Siegle are collaborating on the study I observed at Columbia.
Another surprising result surfaced in an experiment conducted by Naomi Eisenberger at the University of California at Los Angeles: she found that when a study participant was excluded by other participants, the brain regions activated were the same as the regions that would have been activated if this person had been hurt physically.
This new science answers those who believe that kids are misbehaving because parents have become too soft. These critics want us to get tough on kids. This is the camp of Amy Chua, the “Tiger Mother,” who recommends controlling children so that they excel in music, sports, and academics to win spots in selective high schools and colleges. Books like 1-2-3 Magic, The Strong-Willed Child, and Have a New Teenager by Friday encourage parents to assert their power, promising that their kids’ behavior will quickly improve. These methods may “work” if your only goal is to have well-behaved children, regardless of the effect on their mental health. The problem is that the methods of this tradition—yelling at, insulting, and restricting children—have been associated with increases in acting out and depression.
Tough love also reduces kids’ intrinsic motivation. The University of Rochester psychologists Edward Deci and Richard Ryan, for example, found that teachers who aim to control students’ behavior—rather than helping them control it themselves—undermine the very elements that are essential for motivating kids to self-regulate: autonomy, a sense of competence, and belonging. Subjected to such control, kids then have an even harder time learning self-control. When children and young adults don’t have the psychological tools to regulate their emotions, they often find relief in external sources, whether acting out sexually or abusing drugs or alcohol.
Although corporal and verbal punishment may seem to improve children’s behavior in the near term, both carry long-term risks similar to the risks of outright physical abuse of kids—drug and alcohol abuse, depression, heart and liver disease, suicide attempts, and sexual risk-taking.
BRAIN RESEARCH IS ALSO KEY to understanding why children misbehave in the first place. Neuroscientists
know that the prefrontal cortex is central to managing executive function—our capacity to control impulses, prioritize tasks, and organize plans. Research suggests that the prefrontal cortexes of aggressive or oppositional children either haven’t developed or develop more slowly than in typical kids; these children may simply not yet have brains capable of helping them regulate their behavior. Despite what some people assume, executive function doesn’t correlate with intelligence; gifted children can also be impulsive or challenging, despite their intellectual strength and ability to articulate their thoughts. And even children who are right on schedule don’t have a fully developed prefrontal cortex.
I first heard about emotional regulation and brain development at the Parent Encouragement Program (PEP), a parenting education center in Kensington, Maryland, near my home. My husband, Brian, and I went there for classes in 2010, when our youngest was in the throes of the terrible threes. Once I learned how her brain was firing in the middle of her tantrums, and that her prefrontal cortex had barely developed, I stopped taking the outbursts personally. PEP gave me a range of parenting tools to use in setting limits without harming the parent-child relationship. I took every class available. By 2011, I was assisting in classes so that I could stay immersed in the material. In 2013, I began to present parts of the curriculum and then to lead classes myself, eventually becoming a certified parent educator.
In one class I was leading, a student told the story of her three-year-old son coming home from preschool in disgrace for hitting a classmate. When asked why he did it, he said it was an accident. The mom was horrified, sure that this meant he was a liar or perhaps a sociopath.
“You can’t hit someone by accident!” she said.
The Good News About Bad Behavior Page 6
